Right Ventricular Infarction: Right Chest Leads
Report:
Sinus rhythm 96/min
Möbitz 1 (Wenckebach) AV block
3:2 and 2:1 conduction
Acute inferior infarction
Right ventricular infarction
Comment:
V1 and V2 are still there, but reversed, with the right-sided chest lead hook-up. V3R-6R have additional information, viz. significant (≥ 1mm) ST segment elevation. Taken early enough, this is quite sensitive and virtually 100% specific.
As often happens with sick patients the tracing is a bit wobbly and regular P waves are not easy to spot. They should of course sought where expected if one postulates Wenckebach 3:2 block causing the occasional pairs or bradycardia 48/min. The most discernible consecutive ones are in V1 after the transition from the previous set of leads.
In the presence of second degree block there is no need to (routinely) report first degree block (PR intervals of 0.28” here) in the conducted beats ending the long pauses. Incidentally, 2o AV block in inferior infarcts often denotes independent (but not-infarct-related) LAD artery disease.
Below is the standard 12-lead ECG taken on admission Fig 24a). Without the right-sided leads, the RV infarction would have remained undiagnosed. An old criterion, ST elevation in lead 3 being greater than in lead 2, really means that ST segment in lead 1 is depressed – a sign of RCA (as opposed to LCX) occlusion18.
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